Q. When I compare health insurance plans in the exchange for our family, they all show total family deductibles and out-of-pocket maximums (OOPMs). Does that mean we’d have to meet the full family out-of-pocket limit, even for just one person?
A. Ever since 2016, no. And even before that, the answer was usually no.
Prior to 2016, family plans could have aggregate deductibles and OOPMs, or they could have embedded individual deductibles and OOPMs. With an aggregate deductible, you have to meet the full family deductible before any of your after-deductible benefits kick in, even if it’s just one family member with claims. And the OOPM is one total for the whole family, even if just one family member has claims.
But with embedded deductibles, there are individual deductibles built into the family deductible, and each family member is only required to meet the individual deductible before after-deductible benefits kick in for that family member. Once the amounts paid towards individual deductibles meets the total family deductible for the year, everyone in the family is eligible for after-deductible benefits for the rest of the year (on plans like this, the OOPM is also embedded for each person on the plan).
Most health insurance plans already used embedded deductibles and OOPMs prior to 2016. But if you want to contribute to a health savings account (HSA), you need to have an HSA-qualified high deductible health plan (HDHP). And prior to 2016, some HDHPs had aggregate deductibles.
But this changed somewhat with the 2016 Notice of Benefit and Payment Parameters. That regulation clarified that starting in 2016 (for plans that are not grandfathered or grandmothered), no individual can be required to pay more than the individual out-of-pocket maximum set by HHS for that year, even if the individual is enrolled in a family health insurance plan.
For 2021, the individual OOPM is $8,550, and the family OOPM is $17,100 (those are the maximum allowed by law, but many health plans have OOPMs lower than these amounts). Under the rules that took effect in 2016, no single member of a family can be required to pay more than $8,550 in out-of-pocket charges in 2021, regardless of whether the rest of the family has incurred any claims (assuming they stay in-network and comply with the health plan’s rules for referrals, prior authorizations, etc.). This includes people enrolled in family HDHPs, and HHS has clarified that this does not conflict with HSA and HDHP requirements.
(Note that an HDHP could have an aggregate family deductible of, for example, $6,000 and that would still be allowed under the new rules, because even if one family member had to meet that full deductible, it would still be under the maximum allowed individual OOPM. But an HDHP cannot have an aggregate family deductible of $10,000 and require a single family member to meet it before benefits are paid under the plan.)
If you’re browsing plans in the exchange, in many states they only show family deductibles and OOPMs on the multi-plan comparison screen if you enter information for more than one family member. So you may need to look a little further to see what the individual OOPM is. But as long as you have an ACA-compliant health plan, you can rest assured that if only one member of your family needs extensive medical care during the year, your out-of-pocket costs will be capped at no more than $8,550 in 2020, even if your plan has a family OOPM of $17,100.
Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.